Gregory J. Jurkovich
The training and scope of practice of today’s trauma surgeon has evolved into a burgeoning field known as acute care surgery. Acute care surgery both defines an advanced surgical training paradigm and describes a type of surgical practice. The history of this evolution is short, and somewhat cyclic. In 1922 Charles L. Scudder, a general surgeon from Boston who had a strong academic interest in fracture management, established the Committee on Fractures within the American College of Surgeons. This early forerunner of today’s Committee on Trauma was composed of 22 fellows of the College, and the work of this committee encouraged the specialization of trauma surgeons and laid the foundation for the modern concept of quality improvement. As the results of physical force injury from wars, motor vehicle crashes, and interpersonal violence fostered the training of “trauma care” during the mid-20th century, the scope of the trauma surgeon encompassed more than fracture management. In 1950 the Regents of the College authorized the current title—the Committee on Trauma—to emphasize this expanding scope of practice.1
Further advancement of a surgical discipline uniquely dedicated to the care of the injured patient in the United States occurred in the 1960s with the establishment of civilian trauma centers. These early trauma centers were almost exclusively within the domain of city–county hospitals in urban areas such as Chicago, Dallas, and San Francisco, but their impact and influence was rapidly spread by devotees of the charismatic leaders of these centers.2 During the ensuing two decades, trauma surgery became an attractive career based largely on the mentorship of trauma surgeons in urban city–county hospitals who epitomized the master technician, and who developed an academically productive career based on the physiology of the injured patient and lessons learned from the Vietnam War. These trauma surgeons operated confidently and effectively in all body cavities, and perhaps were the last of the “master surgeons” that once were the hallmark of general surgery. Operating primarily in large-volume public, “safety net” hospitals, these surgeons were also typically referred the most challenging surgical problems from the surrounding city or region, particularly if there was a financial disincentive to providing care in a private for-profit hospital. As a result, the city–county or “safety net” hospital trauma surgeons developed an active elective and emergency surgical practice while providing trauma coverage and care to the most critically ill and injured surgical patients.3
The academic success of these leading trauma surgeons (Blaisdell, Carrico, Davis, Freeark, Lucas, Ledgerwood, Mattox, Moore, Shires, Feliciano) fostered their incorporation into university hospitals, and the economic viability of civilian blunt trauma care, particularly in no-fault auto insurance states, led to an expansion of trauma programs out of the safety net hospitals and into private hospitals. The American College of Surgeons contributed to the widespread adoption of trauma programs by the remarkably successful and innovated activities of the Committee on Trauma, including hospital verification, the ATLS course, and the National Trauma Data Bank (NTDB). The federal government fostered the “inclusive trauma system” concept and encouraged the widespread development of trauma centers, in large part by reports of high preventable death rates in nontrauma hospitals, and by publications from the prestigious and influential National Research Council that characterized trauma as “the neglected disease” of modern society.4 The result is that today there are over 1,600 trauma centers in the United States, including 203 Level I centers, 271 Level II centers, 392 Level III centers, and 43 pediatric-specific trauma centers,5,6 with 84% of the population within 1 hour of a Level I or II trauma center.7 This remarkable adaptation of regionalized medical care is nearly unique to trauma, and has been fostered by the recognition of the specialty of its care model and the evidence of its survival benefit.8
Yet the attractiveness of this career, and indeed this type of practice, has been challenged and changed by a number of forces. As trauma surgery became more specialized and expanded out of the domain of the urban safety net hospital, the trauma surgeon no longer remained the “renaissance surgeon” of the urban/county hospitals of the 1970s. This success may in and of itself have paradoxically led to a declining interest and commitment to the practice of trauma surgery. The requirement of a surgical presence for the resuscitation and early decision making was interpreted by many hospitals (and surgeons) as a preclusion to developing a competitive elective practice, thereby discouraging technically proficient and talented clinicians from accepting such positions. Yet perhaps most importantly, as pointed out in an essay by Gene Moore and his “senior active trauma surgeon colleagues,” a declining interest in trauma surgery as a career was influenced by the loss of operative practice due to a number of factors: the nonoperative management of solid organ injuries, effective injury prevention strategies, the emergence of surgical specialties diverting thoracic and vascular injuries away from trauma surgeons, the explosion of technical capabilities of interventional radiology, and the emergence of surgical critical care as a part and parcel of trauma care.9 These forces challenged the viability of a career in trauma surgery, noted by a lack of interest in a trauma by residents and students toward the end of the 20th century. A number of articles have focused on the perceived lack of interest in any on-call practice, the aging of the trauma surgeon workforce, the focus on “lifestyle” residencies that result in highly remunerative and restricted practices, and concern that trauma surgery was primarily a nonoperative field.10–13
Equally pressing has been the continued and unabated emphasis on specialty training beyond core general surgery training. This is a universal trend in medicine as evidenced by the 145 subspecialty certificates awarded by the 24 member boards of the American Board of Medical Specialties (ABMS).14 The exodus of general surgery trainees into surgical subspecialties has created a void of general surgeons with broad-based training who are capable of providing the expertise needed to continue the type of practice once common in city–county hospitals as well as in many rural communities. Many general surgeons, particularly those in group practices, will “subspecialize” within their group by virtue of additional training. Increasingly, surgical subspecialists exhibit less interest in providing emergency and trauma on-call coverage, often concluding that they “aren’t comfortable” or “don’t feel qualified” to do so. Lifestyle interests and an elective practice volume that does not require taking emergency room call to enhance billing often fuel this attitude. This is a reflection of both a demand in surgical manpower that has not yet been addressed and a tendency of hospitals and surgical departments to acquiesce to this demand in order to attract and retain these lucrative and desirable elective clinical practices.
Stitzenberg and Sheldon report that 70% of trainees who complete general surgery residencies pursue further training.15 The greatest interest has been in newer subspecialties, particularly surgical oncology (including breast surgery), endocrine surgery, and “minimally invasive surgery,” which usually includes gastrointestinal and bariatric diseases. In contrast, cardiothoracic surgery and vascular surgery have experienced a decline in interest as evidenced by the marked reduction of applicants to fellowships in these areas and a number of vacant positions in the match. Each of these specialties has had a decline in traditional open operative caseload primarily because of technological advances. Vascular surgeons have responded to this challenge by adding required training in endovascular techniques to their fellowship programs, and have been rewarded by a renewed interest in resident applicant. Cardiothoracic surgery has chosen to increase its focus on thoracic surgical procedures. There is a common thread here. Specialties that have declining operative caseloads are not as attractive to those interested in a career in surgery.16
In response to these changing social, economic, and demographic forces, a joint meeting of the leadership of the American College of Surgeons, the Association for the Surgery of Trauma (AAST), Eastern Association for the Surgery of Trauma (EAST), and Western Trauma Association (WTA) was held in August 2003, with the AAST taking the lead in considering how to restructure the training and practice of trauma surgery to make it a viable, attractive, and sustainable career, in the best interest of patient care, and, importantly, to keep trauma a surgical care disease. The result was the formation of a working group within the AAST to develop a surgical training curriculum that would be attractive to new trainees, and provide the training for a practice that would be viable, sustainable, and, importantly, in the best interest of the patients.17
Surveys of membership of the major trauma societies of the United States were undertaken to document the factors influencing the thinking of current trauma surgeons in both academic and nonacademic settings.18 The average workweek was 80 hours, with one half reporting mandatory in-house night call. Two thirds (67%) of the respondents care for trauma, surgical critical care, and emergency general surgery while on call. Widely valued and enjoyed by these surgeons were the intellectual challenges and the diverse aspect of a trauma career, but the major disincentives to participating in trauma care were the disproportionately poor income, irregular-hour time demands, and an inadequate trauma operative practice spurred by a preponderance of blunt trauma and interference or prohibition from developing an elective general surgical practice. These practicing trauma surgeons largely felt the best current model of trauma care was a training and practice paradigm that included trauma, surgical critical care, and emergency general surgery, and also allowed the option of an elective surgical practice if desired. They generally endorsed an option to include limited orthopedic and neurosurgical skills such as external fixation of uncomplicated long-bone fractures and ICP monitoring, but only if such specialty coverage was unavailable. They envision the ideal practice model as one involving a group practice at a designated trauma center, supported financially by the hospital and regionalized care. They would not mind mandatory in-house night call if such call was necessary for good care, limited in its frequency, predictable, compensated, and earns the next day off.
These results, along with a careful consideration of the needs of society and access to emergency surgical care, result in the development of a recommendation for a new advanced training fellowship to provide the expert surgical workforce to manage trauma and surgical emergencies. The AAST Committee on Acute Care Surgery developed and has promulgated a training curriculum for a specialist that has broad training in elective and emergency general surgery, trauma surgery, and surgical critical care.17 As reflected by the name of this committee, this new surgical specialist has been called the acute care surgeon. A graduate of these fellowship-training programs is trained for a career in managing acute general surgical problems, providing surgical critical care and managing acute trauma. A group practice of these surgical specialists would allow for rotating coverage, with dedicated time off or protected time for elective practice, administration, or research. The training of this surgical specialist requires core general surgery training, as well as advanced thoracic, vascular, and GI surgery, so as to not just allow but also encourage the development of a diverse elective surgical practice, as local practice patterns permit. It has also been proposed that the acute care surgeon specialist could also perform selected and limited neurosurgical, orthopedic, or interventional radiology procedures, with national and local support from these fellow surgical and interventional specialists, and when such subspecialty coverage is not immediately available. While there has been considerable resistance to this part of the proposal, the fact that many hospitals are having difficulty with surgical emergency coverage argues for its addition.19
Current practicing trauma surgeons find that this new specialty makes sense. The broadened training in thoracic, vascular, and GI operative skills and techniques makes this a more desirable surgical specialty. Further training in these areas is required given the shrinking training time brought on by the limited workweek and the siphoning of advanced operative cases by other fellowship trainees. The option of working on a preset schedule allows for a more controllable lifestyle, and potentially makes this specialty more attractive to surgeon who wishes to take a more active part in childrearing or other family activities. This is more than a “surgical hospitalist” who would only cover the on-call window or take care of the patients of other physicians during undesirable hours; rather, the acute care surgeon could well be seen as the most experienced surgeon for most circumstances in most hospitals, a resource for all the medical staff. Also, since this surgical specialist will most commonly be “in-house” 24 hours a day, the likelihood of significant complications due to lack of an experienced surgeon at night and on weekends will be reduced; thus, the cost of care is likely to be reduced. Finally, in academic centers, the ready availability of an in-house surgical specialist will increase the exposure of medical students and residents to surgical attendings. The acute care surgeon specialist will be filling a niche, which now might be termed a void in our provision of acute surgical care to the American public. This void needs to be filled as many of our surgical specialty brethren are increasingly refusing to participate in the surgical call schedule. Although the field of trauma surgery would benefit from these changes, those who will benefit most are our patients. With this in mind, these changes should be welcome in the future of trauma surgery.9
The Acute Care Surgery Fellowship is also designed to have the flexibility to adapt to the possible shortening of core general surgery training to 4 years, or the concept of early specialization. Early specialization is an attractive option to many surgical specialties (but not all) if the core general surgery training can be adequately defined, and completion or advancement dependent on the accomplishment of measures of competency. This is a distinct change from the paradigm of “immersion” training that has been evident in surgical training for the past 50 years. No longer are the work hours unlimited, no longer is independent experience of residents acceptable, and the operative experience of surgery residents continues to fall. Extensive discussions and the development of the Surgical Council on Resident Education (SCORE) curriculum are a direct response to these changes, and hold the possibility of a competency-based core curriculum for all surgeons, with careful integration into early specialization by limiting core general surgery to 3 or 4 years, followed by self-selected area of concentration.20 This pathway for vascular surgery was approved by the American Board of Surgery (ABS) in 2003.21 The training paradigm of the acute care surgeon would fit well within this construct, with core general surgery followed by 2–3 years of trauma, surgical critical care, and advanced general surgical procedures. The genesis of this concept can be traced to recommendations of some members of American Surgical Association committee on the future of surgical training in 2004 and modified in Fig. 6-1.22 This concept of abbreviated core training followed by specialty training ultimately leading to board certification in both general surgery and the specialty of choice is being considered and trialed or considered at this time by thoracic, vascular, and plastic surgery. The ABS has also recently added four new Advisory Councils, including one in Trauma, Burns, and Critical Care, along with Advisory Councils in Surgical Oncology (including breast and endocrine), Transplantation, and Gastrointestinal Surgery (includes endoscopy, hepatobiliary, and bariatric surgery) to provide advise and guidance from these specialty areas,23 and in 2006 the ABS hired Dr Richard H. Bell, Jr, MD, for a newly created administrative leadership role of assistant executive director to specifically facilitate the development of a standardized surgery residency curriculum defined by the SCORE (http://www.surgicalcore.org/). The SCORE is a nonprofit consortium formed in 2006 by the principal organizations involved in US surgical education. SCORE’s mission is to improve the education of general surgery residents (trainees) in the United States through the development of a standard national curriculum for general surgery residency training. This competency-based curriculum is meant to define the specialty of general surgery and provide greater assurance that residents are receiving sufficient training in all areas. The curriculum design is to focus on the 5 years of progressive education and training, which constitute general surgery residency, but prior to independent practice.24
FIGURE 6-1 Proposal for restructured surgical residency training.
ACUTE CARE SURGERY CURRICULUM
Acute care surgery is an advanced surgical training paradigm (fellowship) that is 2 years in length and follows general surgery training (residency). The outline of this curriculum is presented in Table 6-1. The curriculum includes a dedicated minimum of 9 months of surgical critical care, as mandated for Residency Review Committee (RRC)–approved surgical critical care residencies. Only programs with an RRC-approved surgical critical care training residency can be acute care surgery training programs. The remaining 15 months are focused on operative rotations in emergency and elective surgery, with the expectation that there will be at least 12 months of acute care surgical on-call experience, or a minimum of 52 nights of trauma and emergency general surgery call. The 15 months of operative rotations are as a foundation time spent on an intact, functioning, active Acute Care Surgical service. This is supplemented by three core rotations in thoracic, vascular, and hepatobiliary–pancreatic surgery, with the expectation that these rotations will provide adequate exposure to advanced surgical skills and patient care challenges that often are inadequate in core general surgery training to prepare a surgeon for the clinical challenges of emergency surgery. Limited time is suggested on orthopedics and neurosurgical services, with additional elective time to be allocated to meet the needs of the trainee. The expectation is that trainees will be competent in the management of a wide spectrum of acute care surgical needs, and have specific operative competency in the procedures listed in Table 6-2.
TABLE 6-1 Acute Care Surgery Curriculum
TABLE 6-2 Operative Management Principles and Technical Procedure Requirements of Acute Care Surgery Fellowship
Essential elements of the training program will be the operative experience, the presence of an RRC-approved surgical critical care fellowship, and the commitment of the hospital and surgical colleagues to support this new paradigm. The curriculum will meet the ACGME requirements for competency-based training, and the evaluation of the fellows’ performance will reflect that expectation. The ABS, along with the RRC and the American Council on Graduate Medical Education, will be considering how all of surgical training might be evolving over this time as well, and specifically how Acute Care Surgery Fellowship training meets the needs of patients, the populations, and trainees.
The clinical component of these fellowships includes the following key areas:
1. The program should supply the necessary volume and variety of trauma, critical care, and emergency general surgery to assure adequate training of fellows.
2. Each fellow must have ample opportunity and responsibility for the care of patients with acute surgical problems, and the operative experience consistent with developing competency in technical skills and procedures required to provide acute surgical care.
3. Elective general surgery is an essential component of the training of acute care surgeons.
4. Emergency surgical call and trauma call are mandatory components of the training curriculum. Fellows will take a minimum of 52 trauma and emergency surgery night calls during the 2-year fellowship.
5. Elective operative experience in thoracic, vascular, and complex hepatobiliary and pancreatic procedures is encouraged as a means of developing competency in the management of acute surgical emergencies in these anatomic regions.
6. Experience in the diagnosis, management, and operative treatment of neurosurgical and orthopedic injuries is encouraged.
7. Experience with the use of interventional radiology techniques is encouraged.
8. Experience and competency with diagnostic upper and lower GI endoscopy and bronchoscopy are encouraged.
Further details on the program requirements and the currently approved acute care surgery training sites can be found on the AAST Web site (http://www.aast.org/Library/AcuteCareSurgery/Default.aspx). As of mid-2010 there were 7 formally approved training sites, with another estimated 10–20 programs in various stages of considering submitting applications for approved training sites.
The AAST Committee on Acute Care Surgery had considered two other options for the future of trauma surgery: (1) de-emphasize the field from surgery, that is, encourage nonsurgeons to assume responsibility for initial care and SICU management (“United Kingdom model”), and (2) expand the discipline of trauma surgery to include more orthopedics (“European model”). The vast majority of current trauma surgeons are unwilling to abandon trauma care to nonsurgical disciplines.18,25 Others, exampled by the writing of Richardson and Malangoni, have argued that the acute care surgeon is a general surgeon, and that trauma training and practice is part of the broader practice of general surgery.16,26–28 Yet the Louisville group practice of trauma care has closely exemplified the acute care surgeon model, in that their trauma service is designed to include all emergency operations and inpatient consults, and indeed is referred to as “the crucible, where high-volume, high-intensity, results matter, life or death decisions are made, and treatment is provided.”29 Additionally, all (trauma) surgeons are encouraged (and supported) to pursue an elective surgical practice. The acute care surgery paradigm is exactly that, where trauma and general surgery together create a specialist that has broad training in elective and emergency surgery, trauma surgery, and surgical critical care.17 A large number of academic urban trauma centers, mostly safety net hospitals, have always employed this model to ensure optimal care of the injured patient—convinced that emergent torso trauma surgery and elective general surgery are inseparable.30 Moreover, this has always been the scope of practice for rural trauma surgeons, and the possibility of Acute Care Surgery Fellowship training that is tailored to the rural trauma surgeon has great appeal.31–33Likewise, the training of modern military surgeons seems ideally suited to the acute care surgeon model, as exemplified by the incorporation of military surgeons into urban trauma center hospital staffs to expand their clinical operative experience.
The options of including surgical skills and patients with some orthopedic and neurological injuries with the domain of the acute care surgeons (option 2 above) has been challenged by the leadership of neurosurgical societies and the Orthopedic Trauma Association. The initial proposals ranged from including decompressive craniotomies for mass lesions from bleeding and ORIF of all long bone fractures to as little as splinting simple fractures, reducing dislocations, and placing ICP monitors. All have been met with significant resistance, which seems incongruous given the data on lack of specialty coverage from many hospitals for exactly this type of care.25,34 While this represents the model of much of European trauma care,35,36 without the support of these leading organizations, the lack of neurosurgical and orthopedic emergency surgical coverage affecting many hospitals will not be solved by acute care surgery. These societies and professional organizations recognized this, and are taking step to encourage regionalization of trauma/emergency care, and the training and practice interests in trauma/emergency care.
The name acute care surgery was chosen carefully. The term surgical hospitalist, no doubt appealing to hospital administrators, was rejected because the connotation of primarily providing surgical care deemed burdensome and undesirable to other surgical disciplines. Emergency surgery is a recent discipline championed in Europe, including a new World Journal of Emergency Surgery. This name, however, was viewed as suboptimal because of the implication that acute surgical care can be relegated to shift work and is limited to patients seen in the ED. Acute care surgery, as with existing trauma surgery, must provide comprehensive patient management from ED arrival to hospital discharge and seamless 24/7 services.
In some ways current trauma surgeons are responding to the stresses of health care that are external to the discipline of surgery, and are effecting a change in all fields of medicine. The public, payers, and legislators are expecting improvements in both the process and outcome of care. The expectation of a continuous in-house physician is no longer confined to the emergency room, but extends to the ICU, the trauma team, and the inpatient floors. Yet this expectation of continuous presence is challenged by equally strong expectations of a limited workweek, and a nonsustainable health care budget. The demographics of medicine are changing as well, with more women entering higher education, medical school, and surgery. This changing demographic will inevitably impact the future of surgery. Acute care surgery is part of this evolution.
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